Question: In patients with traumatic anterior instability of the
shoulder, what is the effectiveness of arthroscopic and open treatment for
repairing isolated Bankart lesions?
Design: Randomized (allocation
concealed*),
unblinded, controlled trial with 2 years of follow-up.
Information provided by author.
Setting: Department of Orthopaedics at the University of Sassari in
Italy*.
Patients: 60 patients (mean age, 26 y, 87% men) with traumatic
anterior instability of the shoulder, no shoulder symptoms or surgery before
the first traumatic dislocation, =4 episodes of anterior dislocation of the
shoulder, no clinical evidence of multidirectional instability, and
radiological evidence of =30% loss of substance of the humeral head. All
patients underwent arthroscopy to confirm a Bankart lesion of the anterior
aspect of the glenoid labrum, the absence of other capsular and tendon
injuries, and the absence of glenoid fractures. Follow-up study was 100%.
Intervention: 30 patients received arthroscopic treatment. After
arthroscopic examination, the damaged anterior aspect of the labrum was
débrided and mobilized. Through an anterior portal made in the middle
aspect of the glenoid, a 4-mm round bur was used to abrade the anterior border
of the glenoid neck. The glenoid labrum was repaired by way of the Southern
California Orthopedic Institute (SCOI) technique, with use of 3 threaded
metallic suture anchors loaded with No. 1 braided nonabsorbable suture. 30
patients received open treatment. Through a deltopectoral approach, the
subscapularis tendon was longitudinally sectioned approximately 1 cm from its
humeral insertion. After capsulotomy was performed from the lateral side, the
glenoid neck was abraded with a bur or a curet. The labrum was repaired with
use of 3 threaded metallic suture anchors loaded with No. 1 braided
nonabsorbable suture. The capsule and subscapularis tendon were sutured with a
side-to-side repair (no horizontal or vertical shift). Patients in both groups
had the same postoperative regimen.
Main outcome measures: Intraoperative or postoperative
complications, recurrent dislocation, pain, function, strength, and range of
motion.
Main results: There were no intraoperative or postoperative
complications in either group. At the two-year follow-up evaluation, neither
group had a recurrence of dislocation. The total Constant and Rowe Scores were
not different. Only range of motion, evaluated with the Constant score, was
better in the arthroscopy group than in the open-treatment group (a mean score
of 40 ± 1 vs 38 ± 2; p = 0.017).
Conclusions: In patients with traumatic anterior instability of the
shoulder, arthroscopic repair with suture anchors was as effective as open
shoulder repair for isolated Bankart lesions and may improve range of
motion.
The study by Fabbriciani and colleagues adds appreciably to our clinical
knowledge regarding the best treatment for the patient with traumatic
unidirectional anterior instability of the shoulder and an isolated Bankart
lesion after arthroscopic evaluation. Interestingly, only 60 of 104 patients
with recurrent unidirectional anterior instability had an isolated soft-tissue
Bankart lesion at the initial arthroscopic inspection. The study controlled
for preoperative (demographics), intraoperative (arthroscopic pathology), and
postoperative (rehabilitation) factors. In contrast to previous reports that
included different operative fixation between groups and more variable
pathologic conditions to repair, operative fixation with use of 3 metal suture
anchors and nonabsorbable suture was identical in both groups. Thus, by
selecting patients with the same pathologic lesion at diagnostic arthroscopy,
the approach (that is, the operative technique) was isolated as the primary
determinant of outcome.
In this study, there were no complications or recurrent episodes of
dislocations postoperatively in either group. In addition, the techniques,
when selectively applied, resulted in similar scores on the Constant and
Murley rating system and the modified Rowe activity scale. In conclusion,
similar surgical results can be expected for either technique for patients
with traumatic anterior instability and an isolated Bankart lesion when the
technique is employed by an appropriately skilled surgeon. Which technique to
choose will depend on the surgeon's training and skill, but similar outcomes
of well-performed surgery can be expected.